ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By signing this form, you acknowledge receipt of the Notice of Privacy Practices that I have given to you. My Notice of Privacy Practices provides information about how I may use and disclose your protected health information. I encourage you to read it in full.

My Notice of Privacy Practices is subject to change. If I change my notice, you may obtain a copy of the revised notice from me by contacting me at 919-257-1735.

If you have any questions about my Notice of Privacy Practices, please contact me at: 1220 SE Maynard Road, Cary, NC 27511, phone: 919-257-1735.

I acknowledge receipt of the Notice of Privacy Practices of Toni Rabinowitz, Ph.D, LMFT.